Forensic Rehabilitation: Coercion and Recovery

1
Forensic Rehabilitation Coercion and Recovery

• Shawn Mitchell
• Consultant Psychiatrist
• Womens Service, St Andrews Healthcare,
  Northampton, UK

2
Definitions

• Coercion persuade or restrain (an unwilling
  person) by force
• Forensic services treating service users who
  have offended or have presented high risk
  behaviour
• Recovery - a spontaneous and natural event in
  someone who fulfils diagnostic criteria for a
  mental disorder, some who overcome their
  problems without intervention
• the intended consequence of the skilful use of
  the full range of effective treatments
• personal recovery which can occur in the
  context of continuing symptoms or disabilities
• (Ralph and Corrigan 205)

3
Forensic/Secure Treatment Environments on the
increase

• England, Germany, Italy, the Netherlands, Spain
• Sweden
• Increase in the number of forensic hospital beds
  and places in supported housing
• Decrease in the number of in-patient beds in
  Italy and the Netherlands the increase in
  forensic hospital beds and places in supported
  housing has been greater than this decrease
• Priebe et al 2004
• England from 1996 to 2006
• Decrease of NHS psychiatric beds by 29
• Increase in involuntary admissions by 20 per
  annum
• Keown et al 2008

4
Factors contributing to Coercive Practice
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Non-voluntary treatment

• Detention
• Environmental security
• Relational security
• Restraint
• Seclusion
• Enforced treatment medication
• ECT
• behavioural treatments

6
Prevailing Attitudes

• Medical model
• Risk agenda
• Stigma - society
• mental health professionals
• service users

7
Institutionalization

• service users - length of stay
• expectations
• consequences of social exclusion
• staff - expectations of service users
• effects of working with challenging group of
  service users

8
Impaired Decision Making Capacity

• Lack of insight and acceptance can be viewed as
  part of the biological process and therefore with
  treatment will improve
• Substantially more people with schizophrenia lack
  capacity than people with depression or angina
  (Grisso Appelbaum 1995)
• Small subset of service users who have impaired
  decision-making capacity, and therefore,
  arguably, are unable to make decisions in their
  own best interest

9
How to ensure minimal use of coercive
practicesandpromote recovery orientated practice
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Principles

• Mental Health Act (2008)
• Purpose
• Least restriction
• Respect
• Participation
• Human Rights Act
• Right to life - Other people also have rights to
  life and safety (including staff who are caring
  for service users who present serious risks to
  others)

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Decision-making about coercive treatment

• Coercion morally unacceptable unless unavoidable
• Coercion counter-therapeutic (Tyler, Winick)
• Major treatment objective should be facilitation
  of assumption of health responsibility by
  patients themselves
• More efficacious the treatment, the greater the
  justification for coercion
• More serious the sequelae of non-intervention,
  the more justified coercive intervention
• (Freckleton 2008)

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Statutory Frameworks (England Wales)

• Mental Health Act Tribunal
• Second Opinion (only for
• medication and ECT)
• Independent advocates
• Community Treatment Orders
• Mental Capacity Act Independent Mental Capacity
  Advocates
• Advance directives
• Healthcare Commission Recording and monitoring
  of restraint
• Recording and monitoring of seclusion

13
Other possible external review mechanisms

• Second opinions
• Ethics committee
• Service user as guardian for service user
  lacking capacity, appointment of guardian, who
  must be a service user (Munetz Frese 2002)
• Capacity Review Panel act as consultant/advocate
  to all involved parties as to the
  appropriateness of extreme intervention over an
  individual service users objection, possibly
  consisting of a recovering service user who has
  had experience of involuntary treatment, carer
  and psychiatrist (Munetz Frese 2002)

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Consequences of not intervening
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Consequences of delay or omission of treatment

• Ongoing distress experienced by the service user
• Ongoing risks to service users and others due to
  behaviours related to mental disorder
• For service users with a diagnosis of
  schizophrenia
• increased risk of suicide
• increased risk of victimisation, HIV,
  homelessness, violence and incarceration
• partial/non treatment can adversely affect
  the course and outcome of the illness

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From coercion to recoveryorREADY FOR RECOVERY
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Ready for Recovery

• Using recovery form alcoholism as an example
• The voyage of recovery from alcoholism requires
  that the individual be ready to accept the need
  for help.
• Overcoming stuckness (Young and Ensing 1999)
• At times is co-ercion necessary to overcome
  stuckness?
• Stages of recovery (as per Recovery Star ten step
  ladder of change)
• Stuck
• Accepting help
• Believing
• Learning
• Self Reliance
• (MacKeith Burns, Mental Health Providers
  Forum)

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Factors necessary to begin recovery

• Hierarchy of factors
• Safety service user
• staff
• Establishing therapeutic relationship
• Many service users who refuse treatment can come
  to accept, and hopefully respond to treatment by
  careful attention to the therapeutic alliance
  (Weiden, Mott Curcio 1995)
• Perceptions of coercion have less to do with
  legal status (voluntariness) than with
  procedural justice which consists of being
  allowed a voice (being able to say what you
  want) and being treated with respect, concern
  and good faith. Service users who experience this
  feel less coercion even if they become
  involuntary. (Lidz et al, Mac
  Arthur Coercion Study, 1995)

19
Factors necessary to begin recovery

• Negotiating and developing shared goals
  fostering hope and optimism, and also for need to
  change - for change to occur we must first
  recognise that we need to change (Wesley Sowers
  President of the American Association of
  Community Psychiatrist)
• Negotiating factors necessary to achieve goal
• Educating service users about recovery though
  the development of recovery has been led by
  service users it is not innate

20
Increasing service users awareness of recovery

• Making service users aware of recovery through
  general information
• Individualising information about recovery and
  making individual service users aware of their
  entitlements
• Use of peer support
• Use of recovery based outcome measures

21
Factors facilitating recovery

• Staff
• Training
• Support challenges of working with service users
  with high levels of need and risk
• to maintain recovery focus of clinical work
• Monitoring measuring outcome orientation of
  clinical environment

22
Factor facilitating recovery

• Social inclusion Providing opportunities, within
  limitations of secure environments to
  experience challenges and different
  social roles, sometimes with
  encouragement
• Therapeutic safety management

23
Clinical conundrum

• N 33year old woman
• Convicted of three severe offences, one homicide,
  at age of 22, admitted to high secure hospital,
  on restriction order
• Diagnosis Bipolar affective disorder and mixed
  personality disorder
• Occasional intermittent episodes of self harm
• Initial amnesia for homicide, but engaged well in
  individual and group therapeutic sessions
• Progressed through medium and low secure to open
  hospital hostel

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Clinical conundrum

• Granted unescorted community leave
• Tried voluntary work, lead to increase in anxiety
  and sleep disturbance
• Not communicating emotional state to staff
• As a result moved back to open ward and support
  for conditional discharge withdrawn
• Identified need to review relapse prevention
  and coping strategies

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Outcome

• One year later
• Able to allow herself to feel emotions
• Able to talk about index offence
• Improvement in self confidence
• Waiting for discharge
• I thought I was ready for discharge last year,
  but have now managed to progress and achieve
  things I would never have thought possible

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Conclusion

• Coercion
• Need to be honest that it does occur
• That we have guiding principles influencing
  considered decision making when using coercion.
• That there are external means of review of
  coercive practice
• Can be necessary to help a service user to begin
  or continue their recovery
• Establishing a therapeutic relationship can
  minimise the need for coercive practice.